title: Use of imaging in the emergency department: physicians have limited effect on variation.
abstract: OBJECTIVE
  To quantify interphysician variation in imaging use during emergency department (ED) visits and examine the contribution of factors to this variation at the patient, visit, and physician level.
  
  
  METHODS
  This study was HIPAA compliant and approved by the institutional review board of Partners Healthcare System (Boston, Mass), with waiver of informed consent. In this retrospective study of 88 851 consecutive ED visits during 2011 at a large urban teaching hospital, a hierarchical logistic regression model was used to identify multiple predictors for the probability that low- or high-cost imaging would be ordered during a given visit. Physician-specific random effects were estimated to articulate (by odds ratio) and quantify (by intraclass correlation coefficient [ICC]) interphysician variation.
  
  
  RESULTS
  Patient- and visit-level factors found to be statistically significant predictors of imaging use included measures of ED busyness, prior ED visit, referral source to the ED, and ED arrival mode. Physician-level factors (eg, sex, years since graduation, annual workload, and residency training) did not correlate with imaging use. The remaining amount of interphysician variation was very low (ICC, 0.97% for low-cost imaging; ICC, 1.07% for high-cost imaging). These physician-specific odds ratios of imaging estimates were moderately reliable at 0.78 (95% confidence interval [CI]: 0.77, 0.79) for low-cost imaging and 0.76 (95% CI: 0.74, 0.78) for high-cost imaging.
  
  
  CONCLUSIONS
  After careful and comprehensive case-mix adjustment by using hierarchical logistic regression, only about 1% of the variability in ED imaging utilization was attributable to physicians.
authors.affiliation: School of Health Policy and Management, York University, Toronto, Ontario, Canada.
authors.forename: Hannah J
authors.initials: HJ
authors.lastname: Wong
authors.forename: Chris L
authors.initials: CL
authors.lastname: Sistrom
authors.forename: Theodore I
authors.initials: TI
authors.lastname: Benzer
authors.forename: Elkan F
authors.initials: EF
authors.lastname: Halpern
authors.forename: Dante J
authors.initials: DJ
authors.lastname: Morra
authors.forename: G Scott
authors.initials: GS
authors.lastname: Gazelle
authors.forename: Timothy G
authors.initials: TG
authors.lastname: Ferris
authors.forename: Jeffrey B
authors.initials: JB
authors.lastname: Weilburg
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001900:Boston / Q000453:epidemiology; D002648:Child; D002675:Child, Preschool; D003952:Diagnostic Imaging / Q000706:statistics & numerical data*; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008875:Middle Aged; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D014600:Utilization Review; D055815:Young Adult